REPRODUCTIVE AND CHILD HEALTH
8
This chapter presents findings related to maternal and child health in Tanzania. The areas examined include maternity care, vaccinations, and the prevalence and treatment of common childhood illnesses. The 1999 TRCHS information is important as it provides a critical look into the performance of the Maternal Child Health programme in Tanzania. The programme was initiated to support one of the health policy objectives, namely, the reduction of infant and maternal morbidity and mortality. The programme tries to improve the survival and development of women and children, who constitute 75 percent of the population of Tanzania. Provision of medical care during pregnancy and at delivery is essential for the survival of both the mother and the infant. Therefore, the survey results provide an opportunity to identify critical issues affecting the situation of women and children in Tanzania. The information will assist policy makers, planners, and other collaborators in the health sector to formulate appropriate strategies to improve maternal and child health care.
8.1
ANTENATAL CARE
Prevalence and Source of Antenatal Care Table 8.1 shows the percent distribution of the most recent births to women who had a birth in the five years preceding the survey by source of antenatal care received by the mother, according to selected background characteristics. Interviewers asked women about all the people who provided care during the pregnancy; however, if more than one person was mentioned, then the one with the highest qualifications was recorded. The results show that almost all pregnant women in Tanzania (98 percent) receive antenatal care. More than nine in ten births receive antenatal care from a medical professional (93 percent), mostly from health aides (44 percent) or nurses and midwives (43 percent)(see Figure 8.1). Doctors and medical assistants provide about 6 percent of all antenatal care services. Birth attendants provide only 1 percent of antenatal care. Data on antenatal care by mother’s age at birth shows that younger women are more likely to obtain antenatal care from more medically qualified personnel than older women. For example, 53 percent of women below age 20 who gave birth received antenatal care from a doctor or nurse of midwife, compared with 39 percent of women age 35 or above. The same pattern is observed for women according to birth order: lower order births are more likely to receive antenatal care from a doctor or nurse or midwife. Significant variation in antenatal care is noted between rural and urban areas. Urban women are more likely than rural women to receive antenatal care from a doctor, nurse, or midwife (76 versus 41 percent). Half of pregnant women in rural areas receive antenatal care from a less-trained rural medical aide or maternal and child health (MCH) aide, probably because rural people receive most of their health care services from dispensaries that are run by these health aides. In the Mainland, a greater percentage of antenatal care is provided by nurses and midwives than in Zanzibar (44 versus 14 percent); however, in Zanzibar, three-quarters of antenatal care is provided by health aides. Mothers in Unguja were more likely than those in Pemba to attend antenatal care clinics with doctors and nurses or midwives.
Reproductive and Child Health * 93
Table 8.1 Antenatal care Among women who had births in the five years preceding the survey, percent distribution of the most recent births by source of antenatal care received by the mother, according to selected background characteristics, Tanzania 1999 ____________________________________________________________________________________________________ 1 Antenatal care provider _______________________________________________________ Number Background Nurse/ Health Birth of characteristic Doctor Midwife aide attendant Other No one Total births ____________________________________________________________________________________________________ Mother's age at birth 2.2 50.5 39.5 0.6 3.8 3.4 100.0 368 < 20 7.1 43.0 43.8 0.6 4.0 1.5 100.0 1,486 20-34 3.1 35.6 47.6 2.3 5.9 5.6 100.0 329 35+ Birth order 1 2-3 4-5 6+
6.3 7.5 4.6 3.4
49.7 44.4 41.0 36.7
37.1 41.8 49.1 47.7
0.0 1.6 0.0 1.6
3.1 3.8 4.8 5.5
3.9 0.8 0.5 5.2
100.0 100.0 100.0 100.0
498 719 479 487
Residence Urban Rural
15.3 2.8
60.9 37.8
22.0 50.1
0.3 1.0
0.9 5.2
0.5 3.0
100.0 100.0
502 1,681
Mainland/Zanzibar Mainland Urban Rural Zanzibar Pemba Unguja
5.6 15.5 2.7 7.1 2.2 11.2
43.8 62.0 38.5 14.2 7.4 20.1
42.9 20.8 49.4 76.1 88.2 65.9
0.9 0.3 1.1 0.0 0.0 0.0
4.3 1.0 5.3 0.2 0.4 0.0
2.4 0.4 3.0 2.3 1.8 2.8
100.0 100.0 100.0 100.0 100.0 100.0
2,131 487 1,644 52 24 28
Mother’s education No education Primary incomplete Primary complete Secondary+
1.5 6.5 6.1 23.7
31.2 41.7 49.3 47.2
49.5 46.2 41.0 28.9
2.4 0.3 0.4 0.0
8.6 3.3 2.7 0.0
6.8 2.0 0.5 0.2
100.0 100.0 100.0 100.0
581 370 1,143 89
Total 5.7 43.1 43.7 0.9 4.2 2.4 100.0 2,183 _____________________________________________________________________________________________________ Note: “Health aide” refers to both rural medical aides and MCH aides; “birth attendant” refers to both trained and traditional birth attendants. Village health workers are included in the “other” category. 1 If the respondent mentioned more than one provider, only the most qualified provider was considered.
More-educated mothers are more likely to receive antenatal care from qualified medical personnel, such as doctors, nurses, and midwives, than are mothers with less education or no education. Some of this pattern is due to the concentration of doctors, nurses, and midwives, as well as more highly educated women, in urban areas. Number and Timing of Antenatal Visits Pregnant women are advised to start attending antenatal clinics before the 20th week of gestation so that their normal baseline health can be assessed and monitored regularly. At the first antenatal visit, a detailed history should be obtained and a full examination should be carried out. The recommended protocol for antenatal care calls for a woman with a normal pregnancy to visit an antenatal clinic at monthly intervals until the 28th week of pregnancy, then fortnightly until the 36th week, and weekly thereafter until labour begins. If the schedule is followed consistently, it is 94
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anticipated that about 12 to 13 visits will be made. Pregnancy monitoring and detection of complications are the main objectives of antenatal care. The Ministry of Health considers women with the following characteristics to be at higher risk: gravida 5 or over, age under 16 or over 35, height under 150 cm, three consecutive abortions, prior caesarean section, anaemia, oedema, high blood pressure, proteinuria, failure to gain weight, antepartum haemorrhage, and abnormal lie. In the event of any complication, either more frequent antenatal visits are advisable or admission to a hospital may become necessary. Table 8.2 presents data on the number of antenatal visits made by pregnant mothers and the stage of pregnancy at the first visit. Seventy percent of women whose last birth occurred in the five years before the survey made four or more antenatal care visits. However, the median number of antenatal visits is four, which indicates that most women do not make the recommended 12 to 13 antenatal visits. This low number of antenatal care visits is partly because pregnant women start antenatal care late, with the median month of first visit being 5.5 months. Comparing data from the 1991-92, 1996, and 1999 surveys shows only minor variation in antenatal care coverage, the number of visits, and the timing of the first visit. Antenatal Care Content In the TRCHS, women who delivered a child in the five years before the survey were asked several questions about the types of antenatal care they received during the pregnancy that led to their most recent birth. Specifically, they were asked whether they were informed of the signs associated with serious pregnancy complications; whether they received a card listing the immunisations they received; and whether they were given or bought iron tablets or antimalarial medication.
Table 8.2 Number of antenatal care visits and stage of pregnancy Percent distribution of live births in the past five years by number of antenatal care visits (ANC), and by the stage of pregnancy at the time of the first visit, Tanzania 1991-1999 _________________________________________ Number and timing TDHS TDHS TRCHS a of ANC visits 1991-92 1996 1999 __________________________________________ Number of visits None 3.6 2.1 2.4 1 1.1 1.5 2.9 2-3 visits 23.5 22.5 23.1 4+ visits 69.5 69.5 69.9 Don’t know/missing 2.4 4.4 1.6 Total b Median Number of months pregnant at first visit No antenatal care < 6 months 6-7 months 8+ months Don’t know/missing Total b Median
100.0 5.0
100.0 3.9
100.0 4.1
3.6 60.1 34.0 1.7 0.5
2.1 60.5 34.7 1.7 1.0
2.4 61.4 32.0 2.9 1.2
100.0 5.6
100.0 5.6
100.0 5.5
Number of births 8,032 6,916 2,183 __________________________________________ a Refers to most recent birth only b For those with ANC
As shown in Table 8.3, about four in ten women said they were informed about pregnancy complications, while roughly the same proportion said they were given a card that showed the immunisations they had received. Forty-four percent of women said they were given or bought iron tablets during their last pregnancy, and about onethird said they had access to anti-malarial medicine. Differences in antenatal care content by background characteristics are not large. Generally, urban women are more likely than rural women to have received all four items asked about, except that immunisation cards are more commonly given to rural women than to urban women. Similarly, better-educated women are more likely to receive all four antenatal care services than women with less education.
Reproductive and Child Health * 95
Table 8.3 Antenatal care content Among women who have had births in the five years preceding the survey, percentage of the most recent births for which specific antenatal care was received, by content of antenatal care and selected background characteristics, Tanzania 1999 _________________________________________________________________________ Content of antenatal care ____________________________________ Has a Informed card Given/ Given/ of with bought bought Number Background pregnancy immuniiron antiof characteristic complications sations tablets malarials births _________________________________________________________________________ Mother's age at birth 33.2 39.3 45.4 23.0 368 < 20 43.0 40.7 45.4 34.7 1,486 20-34 42.4 33.2 38.8 32.5 329 35+ Birth order 1 2-3 4-5 6+
37.6 42.2 44.0 41.1
38.2 43.4 41.4 32.6
45.9 47.0 44.1 39.5
33.2 30.0 35.9 31.7
498 719 479 487
Residence Urban Rural
52.6 37.9
37.0 40.0
49.8 42.8
41.9 29.6
502 1,681
Mainland/Zanzibar Mainland Urban Rural Zanzibar Pemba Unguja
41.4 52.7 38.0 38.5 26.7 48.4
39.4 37.1 40.0 39.0 37.6 40.1
44.6 49.9 43.0 38.1 29.3 45.6
32.4 42.2 29.5 31.7 35.2 28.7
2,131 487 1,644 52 24 28
Mother’s education No education Primary incomplete Primary complete Secondary+
28.9 41.2 46.2 58.6
33.8 38.6 42.5 37.2
36.8 43.6 86.3 86.5
26.7 27.5 47.5 58.6
581 370 1,143 89
Total 41.3 39.3 44.4 32.4 2,183 ___________________________________________________________________________ Note: “Health aide” refers to both rural medical aides and MCH aides; while “birth attendant” refers to both trained and traditional birth attendants. Village health workers are included in the “other” category. 1 If the respondent mentioned more than one provider, only the most qualified provider was considered.
Tetanus Toxoid Vaccination Another important aspect of antenatal care is tetanus toxoid immunisation. Tetanus is still a relatively common cause of death among newborns in Tanzania and other developing countries. To address this problem, the Ministry of Health requires all women of reproductive age to be vaccinated with tetanus toxoid before they become pregnant. A baby is considered protected if the
96
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mother received two doses of tetanus toxoid during pregnancy, with the second at least two weeks before delivery. However, if a woman was vaccinated during a previous pregnancy, she may only require one dose for the current pregnancy. Five doses are considered adequate to provide lifetime protection. To assess the status of tetanus vaccination coverage, women who gave birth during the five years before the survey were asked if they had received tetanus toxoid injections during the pregnancy for their most recent birth and, if so, how many. The results reveal that 83 percent of women receive tetanus toxoid vaccinations during pregnancy (Table 8.4). However, only 61 percent receive the recommended two doses of the vaccine (Figure 8.1). Younger mothers and women pregnant with their first births are more likely than other women to receive two doses of tetanus toxoid. Urban women are also more likely than rural women to receive two doses of tetanus toxoid during pregnancy. The data imply that a substantial proportion of births in rural areas (around 42 percent) may not be protected against tetanus. Pregnant women in the Mainland are substantially more likely than women in Zanzibar to Table 8.4 Tetanus toxoid vaccinations Among women who had births in the years preceding the survey, percent distribution of the most recent births by number of tetanus toxoid injections received during pregnancy, according to selected background characteristics, Tanzania 1999 ____________________________________________________________________________________ Number of tetanus toxoid injections _______________________________________ Two Number Background One doses Don't know/ of characteristic None dose or more missing Total births ____________________________________________________________________________________ Mother's age at birth 12.8 15.4 70.8 0.9 100.0 368 < 20 15.1 23.1 60.9 0.9 100.0 1,486 20-34 26.9 21.5 51.3 0.3 100.0 329 35+ Birth order 1 2-3 4-5 6+
11.4 14.4 15.2 26.0
14.3 25.9 22.9 21.5
73.1 59.1 61.2 51.6
1.1 0.6 0.7 0.8
100.0 100.0 100.0 100.0
498 719 479 487
Residence Urban Rural
7.9 19.1
16.9 23.0
74.4 57.1
0.7 0.8
100.0 100.0
502 1,681
Mainland/Zanzibar Mainland Urban Rural Zanzibar Pemba Unguja
16.5 7.8 19.1 16.9 19.5 14.6
21.2 16.4 22.7 35.8 35.4 36.2
61.5 75.1 57.4 45.4 43.2 47.2
0.8 0.7 0.8 1.9 1.9 2.0
100.0 100.0 100.0 100.0 100.0 100.0
2,131 487 1,644 52 24 28
Mother’s education No education Primary incomplete Primary complete Secondary+
25.0 15.8 12.7 11.8
24.4 22.5 19.6 25.5
50.0 61.1 66.8 61.0
0.6 0.5 0.9 1.8
100.0 100.0 100.0 100.0
581 370 1,143 89
Total
16.5
21.6
61.1
0.8
100.0
2,183
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Figure 8.1 Antenatal and Delivery Care Indicators ANTENATAL CARE Doctor Nurse/Midwife Health Aide Other/No One
6
43 44
8
TETANUS VACCINATION None One Two+
17
22
61
PLACE OF DELIVERY Health Facility Home
44
DELIVERY ASSISTANCE Doctor Nurse/Midwife Medical Aide Birth Attendant Relative/Friend Other/No One
7 8
28 18
9 0
56
20
29 40
60
80
Percent Note: Percentages are based on most recent birth in the five years preceding the survey. "Birth attendant" includes both trained and traditional birth attendants.
TRCHS 1999
receive two doses of tetanus toxoid (62 versus 45 percent). As expected, the proportion of regnant women who are vaccinated against tetanus increases with education.
8.2
DELIVERY CARE
Place of Delivery Information about the place of delivery provides insight into the quality of services provided since deliveries at health facilities are regarded as more hygienic than those occurring at home. Proper medical attention and hygienic conditions during delivery can reduce the risk of complications and infections that can cause death or serious illness to either the mother or the baby. Table 8.5 presents the distribution of births in the five years preceding the survey by place of delivery. Just under half (44 percent) of births in Tanzania are delivered at a health facility of any kind, while 56 percent are delivered at home (Figure 8.1). It is interesting to note that the proportion of births delivered in health facilities has been declining steadily over time, from 53 percent in 1991-92 to 47 percent in 1996 and to 44 percent in 1999 (Ngallaba et al., 1993: 84 and Bureau of Statistics and Macro International, 1997: 110). The proportion of births that take place in health facilities differs according to characteristics of the mother and the child. Births to younger women, first births, and births to urban women are much more likely than others to take place in a health facility. Women in the Mainland are also somewhat more likely to deliver in a health facility than women in Zanzibar. As expected, births to more-educated women are more likely to take place in hospitals and health centres.
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Table 8.5 Place of delivery Percent distribution of births in the five years preceding the survey by place of delivery, according to selected background characteristics, Tanzania 1999 _________________________________________________________________________ Place of delivery ______________________________ Number Background Health Don't know/ of characteristic facility Home missing Total births __________________________________________________________________________ Mother's age at birth 54.0 46.0 0.0 100.0 575 < 20 43.9 55.8 0.3 100.0 2,286 20-34 27.1 72.6 0.2 100.0 422 35+ Birth order 1 2-3 4-5 6+
59.9 46.6 38.3 25.8
40.0 53.3 61.2 73.7
0.0 0.1 0.5 0.5
100.0 100.0 100.0 100.0
769 1,100 715 698
Residence Urban Rural
82.8 34.5
17.2 65.3
0.1 0.3
100.0 100.0
614 2,668
Mainland/Zanzibar Mainland Urban Rural Zanzibar Pemba Unguja
43.7 83.4 34.7 36.6 26.2 46.3
56.1 16.5 65.0 62.8 72.8 53.4
0.2 0.1 0.3 0.6 1.0 0.2
100.0 100.0 100.0 100.0 100.0 100.0
3,196 591 2,605 86 42 45
Mother’s education No education Primary incomplete Primary complete Secondary+
24.4 44.2 51.0 78.8
75.2 55.7 48.7 21.2
0.4 0.1 0.2 0.0
100.0 100.0 100.0 100.0
907 548 1,711 116
Total
43.5
56.3
0.2
100.0
3,282
Assistance during Delivery The type of assistance a woman receives during childbirth has important health consequences for both mother and child. Therefore, besides collecting information on the place of delivery, the 1999 TDHS collected data on the type of personnel who assisted during delivery. Table 8.6 shows the percent distribution of births in the five years before the survey by type of assistance during delivery, according to background characteristics. Overall, 36 percent of births are assisted by the most highly trained medical personnel (doctors, nurses and midwives), while 8 percent are assisted by lower-level health aides (rural medical aides and MCH aides). About 20 percent of deliveries are assisted by birth attendants (trained birth attendants and traditional birth attendants) or village health workers, some of whom may have received special training. Finally, 29 percent of births are assisted by only relatives and friends of the mother, while 7 percent are delivered without assistance. First births and births to younger women are more likely than other births to be assisted by highly qualified health personnel. This finding is encouraging, given that medical staff recommend that young women and women expecting their first child deliver in a hospital since they are subject to higher risks.
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Table 8.6 Assistance during delivery Percent distribution of births in the five years preceding the survey by type of assistance during delivery, according to selected background characteristics, Tanzania 1999 _______________________________________________________________________________________________________________ 1 Attendant assisting during delivery __________________________________________________________________________ Rural Village Trained Trad. Don't Number Background Nurse/ medical MCH health birth birth Relative/ No know/ of characteristic Doctor Midwife aide aide worker attend. attend. other one missing Total births
_________________________________________________________________________________________________________ Mother's age at birth 9.8 33.2 4.8 5.4 3.0 8.1 5.7 27.6 2.5 0.0 100.0 575 < 20 7.0 29.5 2.3 5.6 1.6 11.3 7.3 28.1 6.9 0.3 100.0 2,286 20-34 6.5 16.0 2.0 3.1 1.3 12.6 5.6 39.2 13.8 0.0 100.0 422 35+ Birth order 1 2-3 4-5 6+
11.5 7.5 6.6 3.7
38.5 31.4 25.1 16.1
5.2 2.2 0.8 2.6
3.9 6.3 6.0 4.3
2.4 1.6 2.0 1.3
7.3 12.0 12.4 11.4
6.8 6.1 7.0 7.5
23.0 27.9 30.9 37.5
0.8 4.8 8.8 15.5
0.4 0.1 0.5 0.1
100.0 100.0 100.0 100.0
769 1,100 715 698
Residence Urban Rural
16.6 5.3
60.1 21.1
3.5 2.5
3.1 5.8
0.7 2.1
6.1 12.0
2.4 7.8
6.0 34.8
1.1 8.4
0.4 0.2
100.0 100.0
614 2,668
Mainland/Zanzibar Mainland Urban Rural Zanzibar Pemba Unguja
7.6 17.1 5.4 1.5 0.8 2.0
28.2 60.0 21.1 35.3 24.5 45.4
2.8 3.6 2.6 0.5 0.2 0.7
5.3 3.1 5.8 3.9 3.1 4.7
1.9 0.8 2.1 0.1 0.3 0.0
10.5 6.0 11.5 26.1 44.3 9.1
6.2 1.9 7.1 28.9 24.1 33.5
30.2 6.1 35.6 2.2 1.2 3.1
7.2 1.1 8.6 0.6 0.0 1.2
0.2 0.4 0.2 0.8 1.4 0.2
100.0 100.0 100.0 100.0 100.0 100.0
3,196 591 2,605 86 42 45
Mother’s education No education Primary incomplete Primary complete Secondary+
5.3 5.1 8.4 20.0
14.1 28.7 33.8 59.6
2.0 3.0 3.1 0.9
4.0 6.4 5.9 0.9
1.4 1.9 2.1 0.0
7.7 10.8 12.9 5.4
8.2 5.1 6.4 8.9
46.5 30.6 21.6 4.1
10.4 8.1 5.3 0.1
0.3 0.1 0.2 0.1
100.0 100.0 100.0 100.0
907 548 1,711 116
7.4 28.4 2.7 5.3 1.8 10.9 6.8 29.4 7.0 0.2 100.0 3,282 Total _______________________________________________________________________________________________________ 1 If the respondent mentioned more than one attendant, only the most qualified attendant was considered.
As expected, births in urban areas are more likely than rural births to be assisted by qualified medical personnel. More than three-quarters of births in urban areas are assisted by doctors, nurses or midwives, compared with only 26 percent of births in rural areas. In the Mainland, births are more likely to be assisted by relatives and friends (30 percent) or to be delivered without assistance; however, in Zanzibar, births are more likely to be supervised by nurses or midwives or by birth attendants, whether trained or traditional. The mother’s education is also associated with the type of delivery assistance. The percentage of births assisted by doctors, nurses and midwives increases from 19 percent of births to women with no education to 80 percent of births to women who have some secondary school. Characteristics of Delivery Other aspects of maternal health that were included in the survey are information on delivery by caesarean section, birth weight, and the mother’s estimate of the baby’s size at birth (Table 8.7). Only 3 percent of babies are delivered by caesarean section, which is fractionally higher than the 2 percent found in the 1996 TDHS. Caesarean deliveries decline among older
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Table 8.7 Delivery characteristics: caesarean section, birth weight and size Among births in the five years preceding the survey, the percentage of deliveries by caesarean section, and the percent distribution by birth weight and by the mother's estimate of baby's size at birth, according to selected background characteristics, Tanzania 1999 _____________________________________________________________________________________________________ Birth weight Size of child at birth ____________________ _____________________________ Delivery Less 2.5 kg Smaller Average Number Background by than or Don't Very than or Don't of characteristic C-section 2.5 kg more know Total small average larger know Total births ____________________________________________________________________________________________________ Mother's age at birth 4.9 6.9 46.9 46.1 100.0 5.7 7.6 86.5 0.2 100.0 575
